Chapter 18 Lymph Nodes
A. General Considerations
6 Where should you look for enlarged nodes?
8 What is the differential diagnosis of a generalizedadenopathy?
One of three processes: (1) a disseminated malignancy, especially hematologic (lymphomas, leukemias, and angioimmunoblastic lymphadenopathy); (2) a collagen vascular disorder (sarcoidosis, rheumatoid arthritis (RA), and systemic lupus erythematosus [SLE]); or (3) an infectious process (mononucleosis, cytomegalovirus [CMV], AIDS, toxoplasmosis, syphilis, tuberculosis, histoplasmosis, coccidioidomycosis, brucellosis, and bubonic plague). Drug reaction can do it, too, and so can intravenous abuse. Some medications (e.g., phenytoin) specifically cause lymphadenopathy; others (e.g., cephalosporins, penicillins, or sulfonamides) do it instead in the context of a serum sickness-like syndrome, with fever, arthralgias, and skin rash (see Table 18-1).
Allopurinol (Zyloprim) | Penicillin |
Atenolol (Tenormin) | Phenytoin (Dilantin) |
Captopril (Capozide) | Primidone (Mysoline) |
Carbamazepine (Tegretol) | Pyrimethamine (Daraprim) |
Cephalosporins | Quinidine |
Gold | Sulfonamides |
Hydralazine (Apresoline) | Sulindac (Clinoril) |
(Adapted from Ferrer R: Lymphadenopathy. Am Fam Physician 58:1313–1323, 1998.)
12 Should one know the regions drained by the various lymphonodal stations?
Yes, since this may unlock the underlying cause. After detecting an enlarged node, always examine the region drained by it (see Table 18-2). Look for infections, skin lesions, or tumors.
Location | Lymphatic Drainage | Causes |
---|---|---|
Submental | Lower lip, anterior floor of mouth, tip of tongue, skin of cheek, teeth, nose | Mononucleosis-like syndromes, Epstein-Barr virus, CMV, toxoplasmosis |
Submandibular | Tongue, submaxillary gland, lips and mouth, conjunctivae | Infections of head, neck, sinuses, ears, eyes, scalp, pharynx |
Anterior cervical (jugular) | Tongue, tonsil, pinna, parotid, larynx, thryroid, upper esophagus | Pharyngitis organisms, rubella, upper respiratory infections, cancer of tongue, larynx, thyroid and cervical esophagus |
Posterior cervical | Scalp and neck, middle ear, skin of arms and pectorals, thorax, cervical and axillary nodes | Mononucleosis, toxoplasmosis, tuberculosis, rubella, otitis media, scalp infections and dandruff, Kikuchi’s disease, lymphoma, head and neck malignancy |
Preauricular | Eyelids and conjunctivae, temporal region, pinna | Disease external auditory canal, ipsilateral conjunctivitis (Parinaud’s syndrome), lymphoma |
Postauricular | External auditory meatus, pinna, scalp | Local infection, but also rubella |
Occipital | Scalp and head | Local infection |
Right supraclavicular node | Breast, lungs, esophagus mediastinum, | Lung, breast, mediastinum |
Left supraclavicular node | Breast, lungs, abdomen via thoracic duct, and pelvis | Lymphoma, thoracic, retroperitoneal, gastrointestinal or pelvic cancer, bacterial or fungal infection |
Axillary | Arm, thoracic wall, breast | Arm infections, cat-scratch disease, tularemia, lymphoma, breast cancer, silicone implants, brucellosis, melanoma |
Epitrochlear | Ulnar aspect of forearm and hand | Infections, lymphoma, sarcoidosis and connective tissue diseases, tularemia, secondary syphilis, leprosy, leishmaniasis, rubella |
Inguinal | Penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal, extremities (benign reactive in shoeless walkers) | Infections of the leg or foot, STDs (e.g., herpes simplex virus, gonococcal infection, syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum), lymphoma, pelvic malignancy, bubonic plague |
STDs = sexually transmitted diseases.
* Modified from Ferrer R: Lymphadenopathy. Am Fam Physician 58:1313–1323, 1998.
14 Why does the patient’s age help?
Because it is the most important predictor of malignancy. Although lymphoproliferative disorders also may affect younger individuals, neoplastic nodes are usually more common in those older than 40 years (Table 18-3). Yet some malignant-looking nodes may actually be benign. Infectious mononucleosis, for example, may often resemble Hodgkin’s disease.
15 What about associated signs and symptoms?
They can be “local” or systemic (Table 18-4). Local findings suggest infection or neoplasm in a specific site (like the swollen nodes and lymphangitic streaks of a skin infection). Conversely, systemic symptoms (such as fever, fatigue, night sweats, and unexplained weight loss) argue in favor of a collagen vascular, lymphoproliferative, or infectious disorder (e.g., tuberculosis [TB]). Still, lack of associated signs or symptoms does not exclude malignancy and thus should not stop a work-up. Finally, remember that the adenopathy of Hodgkin’s disease may become painful after alcohol ingestion.
Disorder | Associated Findings |
---|---|
Common Causes of Lymphadenopathy | |
Mononucleosis-type syndromes | Fatigue, malaise, fever, atypical lymphocytosis |
Epstein-Barr virus* | Splenomegaly in 50% |
Toxoplasmosis* | 80–90% asymptomatic |
Cytomegalovirus* | Often mild symptoms; patients may have hepatitis |
Initial stages of HIV infection* | “Flu-like” illness, rash |
Cat-scratch disease | Fever in 30%; cervical or axillary nodes |
Pharyngitis (group A Streptococcus, gonococcus) | Fever, pharyngeal exudates, cervical nodes |
Tuberculosis lymphadenitis* | Painless, matted cervical nodes |
Secondary syphilis* | Rash |
Hepatitis B* | Fever, nausea, vomiting, icterus |
Lymphogranuloma venereum | Tender, matted inguinal nodes |
Chancroid | Painful ulcer, painful inguinal nodes |
Lupus erythematosus* | Arthritis, rash, serositis; renal, neurologic, hematologic disorders |
Rheumatoid arthritis* | Arthritis |
Lymphoma* | Fever, night sweats, weight loss in 20–30% |
Leukemia* | Blood dyscrasias, bruising |
Serum sickness* | Fever, malaise, arthralgia, urticaria; exposure to antisera or medications |
Sarcoidosis | Hilar nodes, skin lesions, dyspnea |
Kawasaki disease* | Fever, conjunctivitis, rash, mucosal lesions |
Less Common Causes of Lymphadenopathy | |
Lyme disease* | Rash, arthritis |
Measles* | Fever, conjunctivitis, rash, cough |
Rubella* | Rash |
Tularemia* | Fever, ulcer at inoculation site |
Brucellosis* | Fever, sweats, malaise |
Plague | Febrile, acutely ill with cluster of tender nodes |
Typhoid fever* | Fever, chills, headache, abdominal complaints |
Still’s disease* | Fever, rash, arthritis |
Dermatomyositis* | Proximal weakness, skin changes |
Amyloidosis* | Fatigue, weight loss |
* Causes of generalized lymphadenopathy.
(Adapted from Ferrer R: Lymphadenopathy. Am Fam Physician 58:1313–1323, 1998.)